Student Workbook Calculating Dosages Online

Transcription

1 Student Workbook Calculating Dosages Online Sandra Luz Martinez de Castillo, RN, MA, EdD Nursing Professor Los Medanos College Pittsburg, California and Maryanne Werner-McCullough, RN, MS, MNP Nursing Professor Contra Costa College San Pablo, California F. A. Davis Company Philadelphia

2 F. A. Davis Company 1915 Arch Street Philadelphia, PA Copyright 2012 by F. A. Davis Company Copyright 2012 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: Senior Acquisitions Editor: Thomas Ciavarella Director of Content Development: Darlene Pedersen Senior Project Editor: Meghan Ziegler Illustration and Design Manager: Carolyn O Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: / $.25. Copyright 2012, F. A. Davis Company

3 Contents Module Page Basic Math Review 1 Methods of Calculation 8 Systems of Measurement 14 Intake and Output 21 Reading Medication Labels 31 Oral Medications 41 Syringes and Needles 51 Parenteral Medications 61 Reconstitution of Powdered Medications 72 IV Calculations 85 Pediatric Calculations 103 Titration of IV Medications 115 Answers 121 Copyright 2012, F. A. Davis Company

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5 Module: BASIC MATH REVIEW FRACTIONS KEY POINTS: Check the denominators before adding and subtracting fractions. If they are different, find the lowest common denominator, then solve the problem. For multiplication of fractions, just multiply the numerators and the denominators. For division of fractions, remember to invert the second fraction. Then, multiply the numerators and the denominators. Change all mixed numbers to improper fractions before working out the problem. Simplify all fractions to the equivalent fraction. Working With Addition of Fractions Add the following fractions and mixed numbers. 1. 2/5 + 1/5 = 2. 2/ /42 = 3. 2/5 + 2/3 = /8 + 3/4 = /4 + 1/ /2 = / / /4 = / / /3 = 1 Copyright 2012, F. A. Davis Company

6 8. 6 7/ / /6 = / / /8 = / / /8 = Working With Subtraction of Fractions Subtract the following fractions and mixed numbers. 1. 5/6 1/3 = 2. 8/10 1/2 = 3. 7/8 2/3 = /4 1 3/8 = /2 3 1/5 = /6 5 2/3 = /5 6 7/8 = /8 9 2/3 = /7 4 5/6 = /2 3 2/5 = 2 Copyright 2012, F. A. Davis Company

7 Working With Multiplication of Fractions Multiply the following fractions and mixed numbers. 1. 6/8 2/5 = 2. 10/9 1/2 = 3. 5/12 1 1/5 = /8 3/10 = /2 3 3/5 = /3 4 3/7 = /6 1 1/8 = /7 2 2/5 = /8 3 2/3 = /9 2 11/12 = Working With Division of Fractions Divide the following fractions and mixed numbers. 1. 7/10 1/2 = 2. 1/150 1/3 = 3. 6/8 3/5 = /7 1/2 = /2 3 3/4 = 3 Copyright 2012, F. A. Davis Company

8 6. 2 2/5 5 4/5 = /8 7 1/2 = /9 3 1/3 = /7 1/7 = /2 8 3/4 = DECIMALS KEY POINTS: When adding and subtracting decimals, make sure that the decimal points are lined up directly under each other. For multiplication of decimals, count the total number of decimal places in the numbers to be multiplied. Then, count the same number of decimal places in the answer and place the decimal point. When dividing decimals, if there is a decimal point in the divisor, move the decimal point to make the divisor a whole number. Then, move the decimal point in the dividend the same number of decimal places. Place the decimal point in the answer in the same place as in the dividend. Working With Addition of Decimals Add the following decimals = = = = 4 Copyright 2012, F. A. Davis Company

10 Working With Multiplication of Decimals Multiply the following decimals = = = = = = = = = = = = Working With Division of Decimals Divide the following decimals = = = = = = 6 Copyright 2012, F. A. Davis Company

12 Module: METHODS OF CALCULATION SELECT A METHOD OF CALCULATION Linear Ratio and Proportion: 5 mg : 1 tab :: 10 mg : x tab Fractional Ratio and Proportion: 5 mg = 10 mg 1 tab x tab Dimensional Analysis: 10 mg 1 tab = x tab 1 5 mg Formula: 10 mg 1 tab = x tab 5 mg KEY POINTS: Learn the method of your choice; study the setup. To arrive at the correct answer, the units of measurement must be set up so that they cancel. Working With a Method of Calculation Solve the following problems using the method of your choice. 1. The order is for 50 mg. The pharmacy sends 25 mg tablets. How many tablets will the nurse give? 2. The order is for 75 mg. The pharmacy sends 50 mg scored tablets. How many tablets will the nurse give? 8 Copyright 2012, F. A. Davis Company

13 3. The order is for 1 mcg. The pharmacy sends 0.5 mcg pills. How many pills will the nurse give? 4. The order is for 0.5 g. The pharmacy sends 1 g scored tablets. How many tablets will the nurse give? 5. The order is for 1.2 gram. The pharmacy sends 0.4 gram caplets. How many caplets will the nurse give? 6. The order is for 7 mg. The pharmacy sends an elixir labeled 2 mg / ml. How many ml will the nurse give? 7. The order is for 90 mg of a drug. The pharmacy sends 30 mg / 2 ml. How many ml will the nurse give? 8. The doctor orders Lanoxin 125 mcg daily. The nurse finds the following in the patient s medication drawer. How many ml of Lanoxin will the nurse administer? Lanoxin 500 mcg per 2 ml 9 Copyright 2012, F. A. Davis Company

14 9. The order is for IV ranitidine 75 mg q.8h. The pharmacy sends the following vial of ranitidine. How many ml will the nurse give per dose? Ranitidine for Injection 25 mg / ml 10. The order is for 100 mg. The pharmacy sends an oral suspension labeled 12.5 mg / 2 ml. How many ml will the nurse give? 11. The order is for amoxicillin/clavulanate 250 mg t.i.d. The pharmacy sends the following medication. How many days will the bottle last? Amoxicillin/Clavulanate Potassium Tablets 250 mg / tablet Contains 30 tablets 10 Copyright 2012, F. A. Davis Company

15 12. The order is for 125 mg b.i.d. The pharmacy sends a 200 ml bottle labeled 12.5 mg / ml. How many days will the bottle last? 13. The order is for gram of medication IM stat. The pharmacy sends a vial of the medication labeled 0.01 gram per 1.5 ml. How many ml will the nurse administer? 14. The physician orders 21 mg p.o. t.i.d. The nurse has a 100 ml bottle labeled 6 mg / ml. How many ml will the patient receive per dose? 15. The patient is to receive 60 mcg p.o. q.am. The nurse has a bottle labeled 4 mcg / 2 ml. How many ml will the patient receive each day? 16. The physician orders heparin sodium 6000 units subcut q.12h. The pharmacy sends the following vial of heparin. How many ml will the patient receive per dose? Heparin Sodium 10,000 units / ml 11 Copyright 2012, F. A. Davis Company

16 17. The doctor orders 0.4 mg of a drug b.i.d. The pharmacy sends a bottle labeled 0.4 mg per pill. The bottle contains 30 pills. How many days will this bottle last? 18. The patient has an order for amoxicillin oral suspension 500 mg q.8h. The medication drawer contains the following bottle of amoxicillin. How many ml will the patient receive per dose? Amoxicillin Oral Suspension 125 mg in 5 ml For oral use only. Shake well before use. 19a. The doctor orders 0.4 mg of a medication b.i.d. The pharmacy sends a vial labeled 1 mg / ml. How many ml will the patient receive? b. If the vial contains 2 ml, how many doses are available in the vial? 12 Copyright 2012, F. A. Davis Company

17 20a. The order is for heparin 8000 units subcut now. The pharmacy sends the following dose of heparin. Calculate the number of ml the patient will receive. Heparin Sodium 10,000 units / ml Multidose vial containing 4 ml b. How many doses will the nurse be able to give from the above vial? c. If the order is changed to heparin 6500 units subcut daily, how many ml will the patient receive per dose? d. How many doses of 6500 units subcut daily will the nurse be able to give from the multidose vial? 13 Copyright 2012, F. A. Davis Company

18 Module: SYSTEMS OF MEASUREMENT METRIC SYSTEM: UNITS OF MEASUREMENT Kilo Hecto Deka BASIC Deci Centi Milli Micro UNIT KEY POINTS: Memorize the metric units of measurement, metric abbreviations, and the metric line. Working With the Metric System Fill in the blanks with the correct answer L = _ ml L = _ ml mg = _ gram mcg = _ mg mg = _ mcg 6. 2 mg = _ mcg mg = _ gram ml = _ L cm = _ dm km = _ m cm = _ mm kg = _ g 14 Copyright 2012, F. A. Davis Company

19 ml = _ L g = _ mg 15. The patient receives vancomycin 750 mg IV b.i.d. How many g does the patient receive per dose? _ 16. The patient has an order for 0.5 g of ampicillin. How many mg will the nurse administer? _ 17. The patient receives levothyroxine 75 mcg p.o. q.am. How many mg does the patient receive? _ 18. The doctor s order is for digoxin elixir 0.45 mg p.o. now. This dose is equivalent to mcg. _ 19. The weight of a medication is 1.2 kg. This is equivalent to g. _ 20. A wound measures 4 cm in length. This is equivalent to mm. _ 21. The patient has an order for Versed 7 mg IV. The pharmacy sends a vial of Versed labeled 5 mg / ml. How many ml will the nurse administer? _ 15 Copyright 2012, F. A. Davis Company

20 22. The drug order is for lactulose 1000 mg p.o. b.i.d. for the patient. The pharmacy sends a container labeled lactulose 1 g / 10 ml. How many ml will the nurse administer per dose? _ 23. The doctor orders Solu-Medrol 125 mg IV q.12h. for the patient. The pharmacy sends Solu-Medrol 0.25 g / ml. How many ml will the nurse administer per dose? _ 24. The physician writes an order for Benadryl 50 mg orally q.6h. as needed for the patient. The nurse has a bottle of Benadryl labeled 12.5 mg / 5 ml. How many ml will the nurse administer per dose? _ 25. The nurse is preparing to administer 750 mg of vitamin C to the patient at 9:00 AM. In the patient s medication drawer, the nurse finds vitamin C tablets labeled 0.5 g / tablet. How many tablets will the nurse administer to the patient at 9:00 AM? _ 26. The order is for lorazepam 0.5 mg IM now. The nurse has a vial of lorazepam labeled 2 mg / ml. How many ml will the nurse administer to the patient? _ 16 Copyright 2012, F. A. Davis Company

21 HOUSEHOLD SYSTEM: UNITS OF MEASUREMENT UNIT EQUIVALENT ABBREVIATION MEASUREMENT 1 glass 8 ounces -- 1 cup 8 ounces -- 1 teacup 6 ounces -- 1 tablespoon 3 teaspoons T, Tbs 1 teaspoon 5 ml t, tsp 1 drop (drops) -- gt (gtt) 2.2 pounds 1 kilogram lb KEY POINTS: Memorize the units of measurement, equivalent measurements, and symbols used in the household system. Working With the Household System Fill in the blanks with the correct answer. 1. Two Tbs = tsp 2. One ounce = T 3. One-half ounce = tsp 4. Two glasses of juice = oz 5. One cup = oz 6. 2 kg = lb 17 Copyright 2012, F. A. Davis Company

22 7. Three tsp of an antacid = T Fill in the medicine cup below. 2 TBS 1 TBS 1 TSP 1/2 TSP 8. The nurse administers 2 tsp of cough syrup to the patient. How many ml will the nurse administer? Fill in the medicine cup below. _ 30 ml 25 ml 20 ml 15 ml 10 ml 5 ml 9. The patient drinks 3 glasses of water. How many ounces did the patient drink? _ 10. The nurse gives the patient a cup of broth. How many ounces is this? _ 18 Copyright 2012, F. A. Davis Company

23 CONVERSIONS BETWEEN SYSTEMS: UNITS OF MEASUREMENT UNIT EQUIVALENT MEASUREMENTS 1 inch = 2.54 cm 1 oz = 30 ml = 2 T 1 tsp = 5 ml 1 T = 15 ml = 3 tsp 1 glass = 8 ounces = 240 ml 1 cup = 8 ounces = 240 ml 1 teacup = 6 ounces = 180 ml 16 minims = 1 ml 2.2 lb = 1 kilogram KEY POINTS: Memorize the equivalent measurements for the metric and household systems of measurement. Working With Conversions Between Systems Fill in the blanks with the correct answer. 1. 1/2 oz = ml min = ml 2. 1 mcg = mg ml = t 3. 2 T = oz T = t mg = mcg cups = ml g = mg inch = cm g = mg cm = mm ml = oz kg = lb ml = tsp lb = kg mg = g dl = L 19 Copyright 2012, F. A. Davis Company

24 19. The doctor orders thyroxine 0.05 mg p.o. for the patient. Thyroxine is available in 25 mcg tablets. How many tablets will the nurse give? _ 20. The patient drinks two 6 oz cups of coffee for breakfast. How many ml did the patient drink? _ 21. A patient weighs 84 kg. How many pounds does the patient weigh? _ 22. Order: cephalexin 500 mg Available: cephalexin 0.25 gram per tablet How many tablets will the nurse give? _ 23. The physician orders Roxanol 30 mg p.o. q.3h. p.r.n. for pain for the patient. Roxanol is available in a bottle labeled 10 mg / 5 ml. How many tsp will the nurse administer? _ 24. The nurse has an order to administer 600 mcg of a drug subcut to the patient. The pharmacy sends an ampule labeled 2 mg / ml. How many ml will the nurse administer? _ 25. The nurse has an order to administer 75 mg of meperidine hydrochloride IM now. In the narcotic drawer, the nurse finds an ampule of meperidine hydrochloride labeled 100 mg / ml. How many ml will the nurse administer? _ 20 Copyright 2012, F. A. Davis Company

25 Module: INTAKE AND OUTPUT INTAKE AND OUTPUT: EQUIVALENT MEASUREMENTS 1 glass 8 ounces 240 ml 1 cup 8 ounces 240 ml 1 teacup 6 ounces 180 ml 1 styrofoam cup 6 ounces 180 ml 1 popsicle 3 ounces 90 ml ice cubes (melt to 1/2 the original volume) 1 ounce (oz) 30 ml 1 tablespoon (T, Tbs) 15 ml 1 teaspoon (t, tsp) 5 ml KEY POINTS: Intake and output (I & O) are calculated in ml. The size of food containers varies, so it is important for the nurse to become familiar with the specific containers used in each clinical setting. Parenteral intake is calculated as a part of the total intake. Working With Intake and Output Add the following intakes and outputs. 1. The patient is on strict I & O. For breakfast, the patient took 1 cup of coffee, a 4 ounce glass of juice, and 240 ml of milk. For lunch, the patient had a Styrofoam cup of tea and 6 ounces of broth. The patient voided 260 ml at 1000 and 180 ml at Calculate the patient s I & O. I O 21 Copyright 2012, F. A. Davis Company

26 2. The patient is NPO for breakfast. For lunch, the patient was allowed to take 120 ml of water. The patient vomited 180 ml at 1300 and voided 100 ml at At 1400, the patient took 2 T of gelatin and 1/2 glass of apple juice. Calculate the patient s I & O. I O 3. The patient has an NG tube connected to low wall suction. At 0930, the MD wrote an order to clamp the NG tube. The nurse emptied 280 ml of NG drainage. At 1100, the patient vomited 325 ml of bile-colored drainage. The NG tube was reconnected to suction and drained an additional 475 ml by the end of the shift. The patient s wound drainage tube collected 60 ml of serosanguineous fluid. The patient s indwelling urinary catheter drained 270 ml of dark amber urine. Calculate the patient s output. O 4. A patient who had prostate surgery yesterday has an indwelling urinary catheter with a continuous bladder irrigation. He is NPO for breakfast and is started on a clear liquid diet for lunch. He took 6 ounces of broth and 4 ounces of cranberry juice. By the end of the shift, the nurse calculates that 2000 ml of bladder irrigant has infused. The total amount emptied from the urinary bag was 2270 ml. Calculate the I & O. I O 22 Copyright 2012, F. A. Davis Company

27 5. The patient has an IV of D5W infusing at 125 ml / hr. For breakfast, the patient took 1 glass of juice and a cup of coffee. For lunch, the patient took 6 ounces of soup and a 12 ounce can of soda. The patient voided 220 ml at 1000 and 375 ml at Calculate the patient s 8 hr total I & O. I O 6. At 0700, the patient is NPO and has a primary IV of 1 L of D5NS q.10h. infusing continuously. The patient receives gentamicin 80 mg IVPB in 100 ml NS at , and metronidazole 500 mg in 100 ml NS at Calculate the patient s total parenteral intake starting at 0700 and ending at I 7. At 0700, the nurse started an IV of 1 L LR and set the infusion pump at 83 ml / hr. The patient was put on strict I & O. The patient was started on famotidine 20 mg IVPB in 50 ml NS, at 0800 and For breakfast, the patient took 1 cup of coffee and a 6 ounce bowl of cream of wheat. He was NPO except for ice chips for the rest of the shift. The patient took 6 ounces of ice chips and voided 425 ml. Calculate the patient s total I & O starting at 0700 and ending at I O 23 Copyright 2012, F. A. Davis Company

28 8. At 1500, the patient had an IV of 1 L of D5W infusing at 125 ml / hr. For dinner, the patient took 1 glass of juice and an 8 ounce can of nutritional supplement. The IV infiltrated at 1800 and was restarted at The patient received KCl 20 meq IVPB in 100 ml D5W at The patient voided twice for the entire shift (315 ml and 290 ml). Calculate the patient s total I & O starting at 1500 and ending at I O 9. At 2300, the patient had an IV of 1 L of 0.45% NS infusing at 50 ml / hr. The patient had coffee-ground emesis measuring 480 ml at The MD ordered 2 units of PRBCs over 3 hours, followed by an IV of 0.9% NS, to infuse at 150 ml / hr. The nurse discontinued the current IV and started the first unit of PRBC (250 ml) at 0200 and the second unit (270 ml) at The IV of 0.9% NS was started at Calculate the patient s total I & O starting at 2300 and ending at I O 10. At 1500, the patient had 900 ml left in the IV bag. The IV was infusing at 75 ml / hr. At 1900, the IV infiltrated and was restarted 1 hour later. The physician increased the IV rate to 125 ml / hr at Calculate the patient s total parenteral intake starting at 1500 and ending at I 24 Copyright 2012, F. A. Davis Company

29 11. At 0700, the MD ordered 1 L of D5/0.45% NS to infuse at 75 ml / hr for the first 3 hours, and then at 125 ml continuously. For breakfast, the patient took 1 cup of coffee, 8 ounces of milk, and 6 ounces of orange juice. The patient voided 50 ml at 0900 and 75 ml at At 1100, the nurse inserted a Foley catheter per MD order and obtained 425 ml of urine. For lunch, the patient only took 5 ounces of broth. The nurse emptied the Foley catheter at 1500 and obtained 250 ml. Calculate the patient s total I & O starting at 0700 and ending at I O 12. At 0900, the nurse begins the care of a patient who has just been transferred from the post anesthesia care unit. The patient has a new liter of D5/0.9% NS infusing at 125 ml / hr. The patient has an indwelling urinary catheter with continuous bladder irrigation of NS infusing at 75 ml per hour, to keep the catheter free of clots. At 1500, the nurse empties 1575 ml from the urinary catheter. Calculate the patient s total I & O starting at 0900 and ending at I O 13. At 2300, the patient had 850 ml left in the IV bag. The IV was infusing at 50 ml / hr. At 0200, the IV infiltrated and was restarted 2 hours later. The physician increased the IV rate to 75 ml / hr at Calculate the patient s total parenteral intake starting at 2300 and ending at I 25 Copyright 2012, F. A. Davis Company

30 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Intake and Output Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The evening shift nurse learns during the hand-off change of shift report that the assigned patient is NPO, has a primary IV that has infused continuously all shift at 75 ml / hr, and received KCl 20 meq in 100 ml NS at 0900 and In reviewing the patient s documented intake and output from the day shift, the evening nurse is most correct to: 3-11 Intake and Output Oral IV Urine Emesis Other 7-3 NPO Total ml a. question the recorded 100 ml urine output. c. question the administration of the IVPBs. b. recalculate the primary IV intake. d. plan to administer an IVPB of KCl. Rationale / Discussion: 26 Copyright 2012, F. A. Davis Company

31 NASOGASTRIC TUBE FEEDING PROBLEMS KEY POINTS: Preparing diluted tube feedings requires calculating the number of ml of water to add to the formula to make the ordered strength. Information needed to solve the problem includes the amount of formula in the can and the ordered strength. Working With Nasogastric Tube Feeding Problems 1. The doctor orders a 3/4 strength formula tube feeding for the patient. The formula comes in cans containing 240 ml. How much water will the nurse add to the can of formula to make the ordered 3/4 strength diluted tube feeding? 2. The patient receives a 1/3 strength formula tube feeding. The formula can contains 233 ml. How much water will the nurse add to the can to make the 1/3 strength diluted tube feeding? 3. The order is to prepare a 2/3 strength tube feeding of Nepro for a patient with a percutaneous endoscopic gastrostomy (PEG) tube. How much water will the nurse add to the 237 ml can of Nepro to make a 2/3 strength tube feeding? 27 Copyright 2012, F. A. Davis Company

32 4. The physician orders 200 ml of a 1/4 strength tube feeding q.6h. for a patient with an NG tube. The formula can contains 250 ml. How much water will the nurse add to make the 1/4 strength tube feeding? 5. A patient who has been receiving full strength Jevity Plus PEG tube feedings develops diarrhea. The physician orders a diluted tube feeding of 1/2 strength Jevity Plus for the patient. How much water will the nurse add to the 237 ml can of Jevity Plus to make a 1/2 strength tube feeding? 6. The physician orders a 1/4 strength tube feeding of Osmolite at 40 ml / hr for a patient with an NG tube. The Osmolite can contains 237 ml. How much water will the nurse add to make a 1/4 strength tube feeding? 7. A patient has an order for 1/2 strength Pulmocare tube feedings, at 50 ml / hr through a PEG tube. The nurse prepares the dilute formula and has a total volume of 475 ml. According to hospital policy, only 4 hours of tube feeding formula can be hung at a time, to minimize bacterial growth. How many ml of the prepared 1/2 strength formula will the nurse use? 28 Copyright 2012, F. A. Davis Company

33 8. The physician orders a 250 ml bolus NG tube feeding of 3/4 strength q.8h. The formula can contains 237 ml. How much water will the nurse add to make the 3/4 strength tube feeding? 9. The physician orders a diluted tube feeding of 1/3 strength Jevity Plus for the patient. How much water will the nurse add to the 250 ml can of Jevity Plus to make a 1/3 strength tube feeding? 10. The physician orders a 2/3 strength tube feeding of Suplena at 25 ml / hr for a patient with an NG tube. The Suplena can contains 240 ml. How much water will the nurse add to make a 2/3 strength tube feeding? 29 Copyright 2012, F. A. Davis Company

34 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Nasogastric Tube Feedings Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse adds 80 ml of water to 200 ml Jevity formula. The formula tube feeding is started to 0900 at the ordered rate. The patient has a primary IV of NS 0.9% infusing at 80 ml for the 8 hr shift. The nurse emptied 575 ml of urine at 1500, the end of the shift. Which nursing action requires follow up? Date Physician's Orders Intake and Output 2/12 Start NG tube feeding of Jevity 2/3 strength at 50 ml per hour. 7-3 Total ml Oral IV NG Urine Emesis Foley Patient B ID ******* a. The documented NG tube intake should be 400 ml. c. The IV intake is incorrect for the ordered rate. b. The amount of water added to dilute the formula. d. The formula strength should be questioned. Rationale / Discussion: 30 Copyright 2012, F. A. Davis Company

35 Module: READING MEDICATION LABELS READING MEDICATION LABELS KEY POINTS: The essential information found on medication labels includes the following: trade name generic name dosage strength form of the drug route of administration expiration date instructions for mixing recommended dose The useful information found on medication labels includes the following: total quantity manufacturer's name storage information lot number controlled substance symbol Working With Reading Medication Labels Use the medication labels to fill in the answers. 1. a. Trade name b. Generic name c. Dosage strength d. Form of the drug e. Route of administration 31 Copyright 2012, F. A. Davis Company

36 2. a. Generic name b. Dosage strength c. Form of the drug d. Routes of administration e. Controlled substance? yes no f. Multidose Single-dose g. Ordered: 2.8 mg IV. The nurse will give 3. a. Trade name b. Generic name c. Instructions for mixing 32 Copyright 2012, F. A. Davis Company

37 4. a. Generic name b. Dosage strength c. Total quantity d. Routes of administration e. Controlled substance? yes no f. Single-dose vial? yes no g. Ordered: Morphine sulfate 12 mg IV. The nurse will give 33 Copyright 2012, F. A. Davis Company

38 5. Ordered: Augmentin 375 mg p.o. B.I.D. The nurse will give 6. a. Generic name b. Dosage strength c. Routes of administration d. Controlled substance? yes no e. Single-dose vial? yes no 34 Copyright 2012, F. A. Davis Company

39 f. Ordered: Haloperidol 2.5 mg IM. The nurse will give 7. a. Trade name b. Dosage strength c. Route of administration d. Storage information 8. a. Dosage strength b. Routes of administration c. Controlled substance? yes no 35 Copyright 2012, F. A. Davis Company

41 11. a. Trade name b. Ordered: Novolog 6 units subcut now. The nurse will give 12. a. Trade name b. Ordered: Novolin 70/30, 22 units subcut now. The nurse will give 37 Copyright 2012, F. A. Davis Company

42 13. a. Trade name b. Ordered: Humalog 50/50, 17 units subcut q.am. The nurse will give 14. Check the information that is found on the medication label. Trade name Dosage strength Route of administration Storage information Generic name Form of the drug Controlled substance Total amount 38 Copyright 2012, F. A. Davis Company

43 15. Check the information that is found on the medication label. Trade name Dosage strength Route of administration Storage information Generic name Form of the drug Controlled substance Total amount 39 Copyright 2012, F. A. Davis Company

44 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Reading Medication Labels Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse has an order to administer morphine 3 mg IV stat. The nurse selects the following vial. In preparing to administer the ordered dose, it is most important for the nurse to: a. give 1.5 ml of the drug using two vials. c. research the appropriate route of administration. b. call the pharmacist to double check the order. d. not administer this drug. Rationale / Discussion: 40 Copyright 2012, F. A. Davis Company

45 Module: ORAL MEDICATIONS ORAL MEDICATIONS KEY POINTS: In setting up oral medication problems, be sure that the units in the medication order and the available drug match. Use a conversion table to convert unlike units of measurement. When you arrive at the answer, ask yourself if the answer is realistic. Nurses generally administer only 1-2 tablets, and less than 30 ml of medication, per dose. Working With Oral Medications Solve the following problems using the method of your choice. 1. The physician prescribed 0.8 mg of folic acid q.am. The pharmacy sends 0.4 mg tablets. How many tablets will the nurse give? 2. Lanoxin mg is ordered stat. The pharmacy sends 0.25 mg tablets of Lanoxin. How many tablets will the nurse administer? 3. Levothyroxine 0.1 mg is ordered daily. The pharmacy sends 50 mcg tablets. How many tablets will the nurse give? 41 Copyright 2012, F. A. Davis Company

46 4. The doctor orders Ceftin tablets 0.5 g p.o. for a patient. How many tablets will the nurse give? 5. The order is for Dilantin 0.1 g p.o. daily. How many tablets will the nurse give to the patient? 6. Aluminum hydroxide suspension 15 ml is ordered q.i.d. The pharmacy sends a bottle of aluminum hydroxide labeled 320 mg / 5 ml. How many mg is the patient receiving per dose? 42 Copyright 2012, F. A. Davis Company

47 7. The patient receives furosemide 80 mg p.o. b.i.d. The pharmacy sends furosemide oral solution labeled 10 mg / ml. How many ml will the nurse give per dose? 8. The nurse is instructing a patient to take Diflucan 100 mg oral suspension at home. How many tsp will the nurse instruct the patient to take per dose? 9. Diphenhydramine hydrochloride elixir 50 mg p.o. p.r.n. is ordered for itching. Diphenhydramine hydrochloride elixir 12.5 mg / 5 ml is available. How many ml will the nurse give? 10. The order is for atropine 400 mcg tab i p.o. 30 minutes before surgery. The pharmacy sends atropine 0.4 mg tablets. How many tablets will the nurse give? 43 Copyright 2012, F. A. Davis Company

48 11. The nurse practitioner orders nystatin 200,000 units p.o. q.i.d. swish and swallow. The pharmacy sends nystatin 100,000 units / 5 ml. How many ml will the nurse give? 12. Nitroglycerin extended-release tablets 5 mg is ordered q.12h. p.o. The pharmacy sends nitroglycerin tablets labeled 2.5 mg / tablet. How many tablets will the nurse give? 13. Augmentin oral suspension 250 mg q.6h. is ordered for a patient upon discharge. The pharmacy sends the following bottle. How many days will this bottle last? 14. The doctor orders enalapril gram p.o. daily. Enalapril is available in 5 mg scored tablets. How many tablets will the nurse give? 44 Copyright 2012, F. A. Davis Company

49 15. The order is for cyanocobalamin 1 mg p.o. daily. The pharmacy sends cyanocobalamin 1000 mcg tablets. How many tablets will the nurse give? 16. The patient is to receive 20 meq of KCl p.o. q.am. The pharmacy sends a bottle labeled 30 meq / 15 ml. How many ml will the nurse administer? 17. Erythromycin oral suspension 500 mg q.6h. is ordered for a patient. Erythromycin is available in 200 mg / 5 ml. How many ml will the nurse administer? 18. Carvedilol 12.5 mg p.o. b.i.d. is ordered for the patient. In the patient s medication drawer, the nurse finds the following unit dose tablets. The nurse is most correct to administer: Carvedilol mg Carvedilol 6.25 mg (4 tablets available) (2 tablets available) 19. Morphine sulfate oral solution, 120 mg q.4h. around the clock, is ordered for a patient in hospice care. Morphine sulfate is available in 100 mg / 5 ml. How many mg of morphine sulfate will the patient receive per day? 45 Copyright 2012, F. A. Davis Company

50 20. Ceclor oral suspension 375 mg q.8h. is ordered for a patient on discharge. The patient has a prescription for Ceclor 125 mg / 5 ml oral suspension. How many tablespoons will the nurse instruct the patient to take per dose? 21. Mirapex 1500 mg is ordered t.i.d. for a patient. The nurse has Mirapex 0.5 g tablets. How many tablets will the nurse administer for the morning dose? 22. The patient has an order for levetiracetam oral solution 3 g daily. The patient has a bottle of levetiracetam oral solution 100 mg / ml. How many ml will the nurse administer to the patient? 23. The doctor orders furosemide 40 mg oral solution p.o. q.am. Furosemide 8 mg / ml oral solution is available. The nurse has a medicine cup with ounce measurements. How many teaspoons will the nurse administer to the patient? 24. The nurse is preparing to administer the 0900 medications to a patient. In the medication drawer, the nurse finds the following unit dose tablets: digoxin 0.25 mg scored tablets, Captopril 12.5 mg tablets, furosemide 10 mg tablets, Cipro 500 mg tablets. How many tablets of each of the medications will the nurse administer at 0900? Digoxin mg p.o. q.am 0900 Captopril 12.5 mg p.o. q.12h Furosemide 20 mg p.o Cipro 0.5 g p.o. q.12h Copyright 2012, F. A. Davis Company

51 25. Calcitriol capsule 1 mcg p.o. q.am is ordered for the patient. How many capsules will the nurse administer? 26. Cimetidine 450 mg at bedtime is ordered for the patient. The nurse has available the following bottle. How many ml will the nurse administer? 47 Copyright 2012, F. A. Davis Company

52 27. The patient has an order for aspirin 1 g p.o. q.6h. p.r.n. for headache. How many caplet(s) will the nurse administer? 28. Warfarin 5 mg p.o. is ordered for the patient this morning. How many tablet(s) will the nurse administer? 48 Copyright 2012, F. A. Davis Company

53 29. The order is for cefprozil 0.25 g b.i.d. How much water will be added to prepare the suspension? a. How many tsp will the nurse administer? b. 30. The order is for fluconazole 100 mg p.o. now. How much water will be added to prepare the suspension? a. How many tsp will the nurse administer? b. 49 Copyright 2012, F. A. Davis Company

54 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Oral Medications Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Hydralazine 25 mg p.o K-Dur 16 meq p.o Propranolol 60 mg p.o K-Dur 8 meq K-Dur 8 meq Propranolol 60 mg ER Hydralazine 25 mg SITUATION: The nurse is preparing the 0900 medications and finds the patient s unit dose medications in the medication drawer. Which action(s) by the nurse are most appropriate (select all that apply)? a. Give all the 0900 medications. b. Call the pharmacist regarding the propranolol. d. Give the hydralazine and the K-Dur at e. Give the hydralazine and propranolol at c. Call the pharmacist regarding the K-Dur. Rationale / Discussion: 50 Copyright 2012, F. A. Davis Company

55 Module: SYRINGES AND NEEDLES SYRINGES KEY POINTS: The most commonly used syringe, the 3 ml syringe, is calibrated to measure 0.1 ml accurately. Most 3 ml syringes have both minim and ml scales. The TB syringe measures volumes of 1 ml or less and is calibrated to measure 0.01 ml accurately. The TB syringe has minim and ml scales. Larger volume syringes are calibrated in 0.2 ml or 1 ml increments. Insulin is measured in units and is drawn up in an insulin syringe. The standard insulin syringe is calibrated by 2 unit increments. Low dosage insulin syringes are calibrated in 1 unit increments. Working With Syringes Shade in the syringe with the indicated amount of medication ml 1/ / / ml m ml 51 Copyright 2012, F. A. Davis Company

57 ml ml units of insulin units of insulin units of insulin units of insulin units of insulin / / / USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN ml UNITS UNITS 100 UNITS 50 UNITS 50 UNITS 53 Copyright 2012, F. A. Davis Company

58 units of insulin USE U-100 INSULIN UNITS units of insulin USE U-100 INSULIN ml The nurse receives a vial of Enalaprilat from the pharmacy. The order is to administer mg of Enalaprilat IV. Shade in the ml that will be administered to the patient. 1/ / ml 100 UNITS 2 1/2 20. The nurse has an order to administer Glycopyrrolate 150 mcg IV. Available is Glycopyrrolate 0.4 mg / 2 ml. Shade in the amount of Glycopyrrolate that will be administered to the patient m ml 54 Copyright 2012, F. A. Davis Company

59 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Syringes Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: After calculating the ordered dose of a medication, the nurse determines that the patient is to receive 5 ml of the medication IM. The nurse selects a 5 ml syringe to administer the ordered dose. The nurse: a. has correctly determined the most appropriate syringe to measure and administer this dose accurately. b. needs to contact the physician and request a higher dosage strength of the medication. c. needs to contact the pharmacist to ensure that the ordered dose has been correctly calculated. d. should divide the medication into two injections, using two 3 ml syringes. Rationale / Discussion: 55 Copyright 2012, F. A. Davis Company

60 NEEDLES KEY POINTS: Needles are identified by two numbers: length and gauge. Needle length is measured in inches. Needle gauge refers to the diameter. The larger the number of the gauge, the smaller the diameter of the needle. Needles are packaged in standard sizes with syringes for IM, ID, subcut, and IV use. Working With Needles Choose the correct needle size for the following injections. 1. A subcut injection of insulin 2. An IM injection 3. A TB skin test 4. An IM injection for an obese person 5. A subcut injection into the upper arm 6. Drawing up viscous medication from a vial 56 Copyright 2012, F. A. Davis Company

61 Choose the correct syringe and needle for the following injections. Fill in the syringe. 1. Meperidine 75 mg (1 ml) IM a m 21G ml b. 22G 1 1/2 1/ / /2 2. Filgrastim 300 mcg (1 ml) subcut a m 28G 3/ ml b. 25G 5/8 1/ / /2 3. Heparin 5000 units (0.67 ml) subcut 25G 5/8 a m ml b. 28G 1/ USE U-100 INSULIN UNITS 57 Copyright 2012, F. A. Davis Company

62 4. Hepatitis A vaccine 1 ml IM a ml 18G 1/2 b. 23G 1 1/2 1/ / /2 5. Ketorolac 60 mg (2 ml) IM a m 21G 1 1/ ml b. 22G 1 1/2 1/ / /2 6. Humulin Regular insulin 17 units subcut a. 28G 1/ USE U-100 INSULIN UNITS b. 28G 1/ USE U-100 INSULIN UNITS 58 Copyright 2012, F. A. Davis Company

63 7. Humulin Regular insulin 6 units and Humulin NPH insulin 13 units subcut a. 28G 1/2 5 USE U-100 INSULIN UNITS b. 28G 1/ USE U-100 INSULIN UNITS 8. Heparin 1000 units (0.1 ml) subcut a m 25G 5/ ml b. 25G 5/8 1/ / /2 9. Morphine sulfate 10 mg (16 minims) subcut a m 21G ml b m 25G 1/ ml 59 Copyright 2012, F. A. Davis Company

64 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Needles Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Date 7/29 Medication Record Heparin 5000 units subcut into the abdomen q.am 0900 SITUATION: To administer this medication safely, it is most correct for the nurse to use a: a. 18G 1 Patient T b. c. 20G 1 1/2 22G 1 d. 25G 1/2 Rationale / Discussion: 60 Copyright 2012, F. A. Davis Company

65 Module: PARENTERAL MEDICATIONS PARENTERAL MEDICATIONS KEY POINTS: In setting up parenteral medication problems, be sure that the units in the medication order and the available drug are the same. Use a conversion table to convert unlike units of measurement. When you arrive at the answer, ask yourself if the answer is realistic. Nurses generally administer 3 ml or less of a parenteral medication. With insulin, just draw up the total units ordered. Working With Parenteral Medications Use the method of your choice to solve the problems. 1. The physician prescribed 0.1 mg of folic acid IM. The pharmacy sends the following ampule. How many ml will the nurse give? Folic Acid 0.5 mg / ml 2. Meperidine HCl 75 mg is ordered stat. Meperidine HCl 50 mg / ml is available. How many ml will the nurse administer? 61 Copyright 2012, F. A. Davis Company

66 3. Heparin sodium 5000 units subcut q.12h. is ordered for a patient. The pharmacy sends a vial labeled heparin sodium 20,000 units / ml. How many ml will the nurse give? 4. Procaine penicillin G 1.2 million units IM is ordered for a patient. The pharmacy sends procaine penicillin G 600,000 units / ml. How many ml will the nurse give? Fill in the syringe. 5. The preoperative order is morphine sulfate 9 mg with glycopyrrolate 0.08 mg IM stat. Morphine sulfate 15 mg / ml and glycopyrrolate 200 mcg / ml are available in the medication drawer. Calculate the preoperative medications. Morphine sulfate: Glycopyrrolate: Fill in the syringe with the total amount. 1/ / /2 1/ / /2 62 Copyright 2012, F. A. Davis Company

67 6. Hydromorphone 1 mg subcut q.3h. p.r.n. for pain is ordered for a patient. Hydromorphone 10 mg / ml is available in the narcotic drawer. How many ml will the nurse give? Fill in the ordered dose in each syringe m ml 1/ / /2 7. The order is for atropine 400 mcg subcut now. The pharmacy sends the following multidose vial. How many ml will the nurse give? 8. The physician orders morphine sulfate gram. Morphine sulfate is available in 15 mg / ml How many minims will the nurse give? Fill in the syringe m ml 63 Copyright 2012, F. A. Davis Company

68 9. Epoetin 12,000 units subcut 3 x / week is ordered. The pharmacy sends a vial of epoetin labeled 20,000 units / ml. How many ml will the nurse give? Fill in the ordered dose in each syringe m ml 10. The doctor orders ampicillin 250 mg. The pharmacy sends a vial of ampicillin labeled 1 g / ml. How many ml will the nurse give? Fill in the ordered dose in the most appropriate syringe. 1/ / /2 1/ / / m ml 11. The physician orders phenytoin 125 mg IM. The nurse prepares to draw up the medication from a vial labeled phenytoin 50 mg / ml. How many ml will the nurse give? 64 Copyright 2012, F. A. Davis Company

69 12. Humulin NPH insulin 23 units q.am is ordered for a patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS USE U-100 INSULIN UNITS 13. Humulin N insulin 35 units and Humulin R insulin 7 units q.am are ordered for a patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS UNITS USE U-100 INSULIN 14. Humulin 70/30 insulin 21 units q.am is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS UNITS USE U-100 INSULIN 65 Copyright 2012, F. A. Davis Company

70 15. Humulin 50/50 insulin 19 units q.am is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS USE U-100 INSULIN UNITS 16. Humulin R insulin 2 units is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN 17. Humulin NPH insulin 22 units and Humulin Regular insulin 7 units are ordered stat. How much insulin will the nurse give? Fill in the most appropriate syringe UNITS UNITS UNITS UNITS USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN 66 Copyright 2012, F. A. Davis Company

71 18. Adenosine 2.7 mg IV is ordered. The pharmacy sends a 2 ml single-dose vial of adenosine. How many ml will the nurse administer? 19. Heparin 4500 units subcut is ordered. The nurse has the following vial of heparin. How many ml will the nurse administer? 20. The nurse receives an order to administer ranitidine 20 mg IVP. How many ml will the nurse administer? 67 Copyright 2012, F. A. Davis Company

72 21. Cyanocobalamin 0.5 mg is ordered subcut. To carry out this order correctly, the nurse will administer how many ml of cyanocobalamin? 22. The physician orders amikacin 0.25 g IM q.12h. How many ml will the nurse administer per dose? 23. Enalaprilat mg IVP q.6h. is ordered. After drawing up the ordered dose, how many ml will the nurse discard from the vial? 68 Copyright 2012, F. A. Davis Company

73 24. The MD orders granisetron 2000 mcg direct IV 30 minutes prior to chemotherapy. Pharmacy sends the following vial. How many ml will the nurse administer to the patient? 25. Adenosine 9 mg is ordered direct IV stat for the patient. Pharmacy sends the following vial. How many ml will the nurse administer? 26. Enoxaparin 150 mg / 1 ml prefilled syringe is available. The nurse has an order for enoxaparin 90 mg subcut. How many minims will the nurse administer? 27. The nurse has a 5 ml multidose vial of heparin labeled 20,000 units per ml. The order is to administer 15,000 units of heparin subcut to the patient q.12h. How many ml will the nurse administer? Fill in the syringe m ml 69 Copyright 2012, F. A. Davis Company

74 28. The patient has an order for metoclopramide 5 mg IM stat. The pharmacy sends a single-dose vial of metoclopramide. How many ml will the nurse administer to the patient? 29. The physician writes an order for terbutaline 250 mcg subcut for the patient who is wheezing. The nurse has the following vial of terbutaline. How many ml will the nurse administer to the patient? 30. The patient has an order for morphine sulfate 1.5 mg direct IV injection. How many ml will the nurse administer to the patient? 70 Copyright 2012, F. A. Davis Company

75 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Parenteral Medications Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse has an order to administer levothyroxine mg IVP q.am. How many ml will the nurse draw into the syringe? a ml c. 1.5 ml b ml d ml Rationale / Discussion: 71 Copyright 2012, F. A. Davis Company

76 Module: RECONSTITUTION OF POWDERED MEDICATIONS SINGLE-STRENGTH RECONSTITUTION KEY POINTS: In single-strength reconstitution, the manufacturer identifies one amount of diluent to add to the powdered medication. The dosage strength of the mixed medication is used to calculate the amount to give to the patient. Information needed to work with single-strength reconstitution problems includes the type and amount of diluent, dosage strength of the mixed medication, length of time the solution will remain stable, and storage information. Once the medication is reconstituted, the nurse writes the date and time of reconstitution and the nurse s initials on the medication label. Working With Single-Strength Reconstitution Solve the following single-strength reconstitution problems. 1. The physician orders cefazolin sodium 0.25 g IM q.8h. The pharmacy sends a 1 g vial of sterile cefazolin powder with the following mixing instructions: For IM use, add 2.5 ml sterile water for injection and shake. Provides a volume of 3.0 ml (330 mg / ml). a. How much diluent will be added to the cefazolin sodium powder? 72 Copyright 2012, F. A. Davis Company